The Diabetes Unmet Need with Basal Insulin Evaluation (DUNE) study was a prospective evaluation of 3139 consecutively enrolled type 2 diabetes patients from 28 countries who started insulin at the point of recruitment or had been using it for less than 12 months prior (average 5.7 months).

At baseline, average HbA1c was 9.14% (76.44 mmol/mol) in the 1716 study participants who were newly starting on insulin and 8.56% (70.01 mmol/mol) in the 1423 who were already using it. During the next 12 weeks it fell by a respective 1.4% (15 mmol/mol) and 0.8% (8.7 mmol/mol).

When we turn to insulin we need to use it effectively in type 2 diabetes and this may need a team approach in which your staff or diabetes educators or clinical pharmacists can be called in to help patients achieve their target and stick to the treatment plan.

Overall, 27% of patients achieved their HbA1c target, which Luigi Meneghini (University of Texas Southwestern Medical Center, Dallas, USA) and co-researchers say is in line with other real-world studies, in contrast to treat-to-target intervention trials, which report rates of 40–50%. However, they note that these rates are achieved with markedly higher insulin doses than were used in this study.

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The average daily insulin dose at baseline was 14 and 23 U/kg in the new and recent insulin starters, respectively, and this rose only by an average 0.08 U/kg in the two groups overall during follow-up.

The researchers note that virtually all (99.7%) study participants were given individualized HbA1c targets by their physicians, generally between 7.0% and 7.5% (53 to <58 mmol/mol), rather than the recommended level of less than 7.0%. The most common reasons for this were patient age, acceptability of the requirements to meet a lower target (such as blood glucose monitoring and lifestyle changes), and comorbidities. Physicians also tended to set more relaxed targets for people they considered to be at higher risk for complications of hypoglycemia.

Given this near complete use of individualized targets, the team suggests that the accepted definition of glycemic control “might need to be reconsidered for real-world studies.”

Self-reported symptomatic hypoglycemia occurred in 14% and 18% of new and previous insulin users, respectively. However, in multivariate analysis, people who remained free of hypoglycemia were also a significant 35% less likely to achieve their HbA1c targets than those who experienced a hypoglycemic episode, and the likelihood of achieving target rose with increasing number of episodes.

“As participants who did not experience symptomatic hypoglycemia were less likely to achieve glucose targets, factors other than experiencing hypoglycemia, or the fear thereof, may have contributed to targets not being achieved,” say the researchers.